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J Oral Maxillofac Surg 65:2206-2210, 2007

Comparison of 2 Flap Designs in the Periodontal Healing of Second Molars After Fully Impacted Mandibular Third Molar Extractions
Tugrul Krtloglu, DDS, PhD,* Emel Bulut, DDS, PhD, Mahmut Smer, DDS, PhD, and nan Cengiz, DDS I
Purpose: This investigation compared the effects of different ap designs on the periodontal health status of the

mandibular second molar after the extraction of the adjacent impacted third molar. Patients and Methods: Eighteen patients aged 16 to 32 years who required removal of bilateral impacted mandibular third molars were included in this study. The periodontal health of the second molar was evaluated preoperatively and at 1 week, 2 weeks, 4 weeks, and 12 months postoperatively. The third molars were removed by using the 3-cornered ap on the left side of the jaw and modied Szmyd ap on the right side. Results: The mean probing depth (PD) at distal and buccal sites was signicantly different between the aps at 1 week, 2 weeks, and 4 weeks postoperatively (P .05). There were no signicant differences in preoperative and 1 year postoperative mean PD between the 2 aps (P .05). There was no signicant difference in mean clinical attachment level between the ap sites at 1 year (P .05). Conclusion: The modied Szmyd ap, which leaves intact gingiva around the second molar, has better primary periodontal healing than the 3-cornered ap after surgical removal of the fully impacted mandibular third molar. 2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:2206-2210, 2007 Surgical removal of impacted third molars is the operation carried out most commonly by oral surgeons. The optimal management of the surgical extraction of the impacted third molar is a highly relevant issue to maintaining the periodontal health of the adjacent second molar. Dehiscence can take place distal to the second molar during primary wound healing after extraction of the impacted third molar and this area may heal secondarily. Secondary wound healing can cause loss of attachment and gingival defects distal to
Received from the Faculty of Dentistry, University of Ondokuz Mayis, Samsun, Turkey. *Assistant Professor, Department of Periodontology. Assistant Professor, Department of Oral and Maxillofacial Surgery. Assistant Professor, Department of Oral and Maxillofacial Surgery. Research Assistant, Department of Periodontology. Address correspondence and reprint requests to Dr Krtloglu: University of Ondokuz Mayis, Faculty of Dentistry, Department of Periodontology, 55139 Kurupelit-Samsun, Turkey; e-mail: tugkir@yahoo.com
2007 American Association of Oral and Maxillofacial Surgeons

the second molar.1 The effect of impacted third molar extraction and different ap techniques on periodontal health distal to the adjacent second molar has been investigated with conicting results in several studies.1-9 To increase understanding of this issue, this investigation compared the effect of different ap designs on periodontal health status of the mandibu-

FIGURE 1. An illustration of the incision for the 3-cornered ap. Krtloglu et al. Modied Smyd Flap Versus 3-Cornered Flap. J Oral Maxillofac Surg 2007.

0278-2391/07/6511-0012$32.00/0 doi:10.1016/j.joms.2006.11.029

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KRTLOGLU ET AL

2207 vertical ( 26) or mesioangular (26 to 75) classication.


CLINICAL EXAMINATION

FIGURE 2. An illustration of the incision for the modied Szmyd ap. Krtloglu et al. Modied Smyd Flap Versus 3-Cornered Flap. J Oral Maxillofac Surg 2007.

lar second molar after the adjacent impacted third molar extraction.

Clinical measurements were carried out on each patient preoperatively and at 1 week, 2 weeks, 4 weeks, and 12 months postoperatively. The plaque index (PI)10 and the gingival index (GI)11 were evaluated on the buccal, distal, and lingual surfaces of the adjacent second molar. The pocket depth (PD) and clinical attachment loss (CAL) were evaluated on the distobuccal, mid distal, distolingual, lingual, and buccal surfaces of the second molar. Acrylic stents were constructed for use as probing guides preoperatively and postoperatively. All measurements were carried out by the same examiner using Williams periodontal probe (Hu-Friedy, Chicago, IL) to eliminate interexaminer variability. The PD was dened as the distance in millimeters (mm) from the free gingival margin to the bottom of the pocket. The CAL was dened as the distance in mm from the cementoenamel junction to the bottom of the pocket.
SURGICAL TECHNIQUES

Patients and Methods


The study population comprised 18 patients (12 females, 6 males) who had been scheduled for bilateral surgical removal of their mandibular third molars at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ondokuz Mayis University in Samsun, Turkey. Their ages ranged from 16 to 32 years, with a mean of 20.8 years. All patients were in good general health and were not using any medication that would inuence wound healing after surgery. Indication of impacted third molar removal resulted from prophylactic or orthodontic considerations. The preoperative examination consisted of intraoral examination and panoramic radiographs. An alginate impression of the lower arch was also taken at this time for fabrication of an acrylic stent. The participants were selected according to the following criteria: 1) presence of bilateral and fully impacted mandibular third molars; and 2) similarly positioned impacted mandibular third molars with

All surgical procedures were carried out by the same surgeon. For each patient, bilateral mandibular third molars were removed during the same operation. The patients were treated under aseptic conditions using local anesthesia. The local anesthetic was articaine solution with 1:100.000 epinephrine (Ultracaine DS; Aventis, Istanbul, Turkey). Technique I The 3-cornered ap was used on the left side of the jaw. It consisted of a horizontal incision in the mandibular ramus and a sulcular incision starting near the mesiobuccal edge of the second molar and extending to its distal surface. A relieving incision was made in the mesial region without cutting the interdental papilla. The horizontal incision was terminated at the distal surface of the distobuccal cusp of the mandibular second molar (Fig 1). Technique II The Szmyd ap was modied and used on the right side of the jaw. An incision was made along the post

Table 1. PLAQUE INDEX ON THE DISTAL SURFACE OF THE SECOND MOLAR PREOPERATIVELY AND POSTOPERATIVELY

Flap Technique Technique II Technique I P value

Preoperative 0.56 0.61 NS 0.12 0.12

1 Week 1.72 1.72 NS 0.11 0.11

2 Weeks 0.94 1.00 NS 0.21 0.21

4 Weeks 0.56 0.61 NS 0.17 0.18

1 Year 0.56 0.56 NS 0.17 0.17

Abbreviation: NS, not signicant. Krtloglu et al. Modied Smyd Flap Versus 3-Cornered Flap. J Oral Maxillofac Surg 2007.

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MODIFIED SMYD FLAP VERSUS 3-CORNERED FLAP

Table 2. GINGIVAL INDEX ON THE DISTAL SURFACE OF THE SECOND MOLAR PREOPERATIVELY AND POSTOPERATIVELY

Flap Technique Technique II Technique I P value

Preoperative 0.61 0.67 NS 0.50 0.49

1 Week 1.78 1.89 NS 0.43 0.32

2 Weeks 1.11 1.33 NS 0.58 0.59

4 Weeks 0.56 0.83 NS 0.62 0.62

1 Year 0.60 0.63 NS 0.52 0.51

Abbreviation: NS, not signicant. Krtloglu et al. Modied Smyd Flap Versus 3-Cornered Flap. J Oral Maxillofac Surg 2007.

molar triangle, starting on the ramus and terminating 2 mm behind the second molar. From this point it was extended down the buccal side (Fig 2). Ostectomy was carried out with a rotary instrument under constant irrigation with sterile saline. After removal of the tooth, the extraction socket was cleansed carefully, including removal of follicular remnants. The wound was closed with 2 single 3-0 silk sutures, which were removed at a second visit 7 days after the extraction. After the surgical procedure, all the patients were treated for 7 days with amoxicillin (Largopen, 1,000 mg 3 1; Bilim, Istanbul, Turkey), urbiprofen (Majezik, 100 mg 2 1; Sanovel, Istanbul, Turkey) and 0.2% chlorhexidine gluconate (Klorhex, 2 1; Drogsan, Istanbul, Turkey). The Wilcoxon test was used for statistical analyses. A P value of less than .05 was considered statistically signicant.

were found for the gingival index. There were significant differences, however, in gingival index scores among the preoperative, rst and second week postoperative measurements in both types of aps.
PROBING DEPTH

Results
PLAQUE INDEX

The mean plaque index for distal surfaces for the technique I and technique II aps is presented in Table 1. There were no signicant differences in plaque scores between the 2 aps preoperatively and postoperatively. However, a signicant increase was observed in plaque at 1 week at both ap sites (P .05) but they decreased after the rst week.
GINGIVAL INDEX

Table 2 shows the mean gingival index on the distal surfaces of the second molar with both types of aps. No signicant differences between the 2 types of aps

Tables 3 and 4 show the mean PD for the distal and buccal surfaces of the second molar. The mean PD at the distal and buccal sites was signicantly different between the 2 types of ap at 1 week, 2 weeks, and 4 weeks postoperatively (P .05). There were no signicant differences in preoperative and 1 year postoperative mean PD between 2 types of aps (P .05). Values for the 3-cornered ap showed signicant increases in distal and buccal probing depth at 1 week, 2 weeks, and 4 weeks after surgery (P .05). There was also a signicant difference on the distal surface of the second molar at 1 week and 2 weeks after surgery for modied Szmyd ap site (P .05) and on the buccal surface of the second molar at 1 week after surgery at modied Szmyd ap sites (P .05). There were no signicant differences on the lingual surface of the second molar between the 2 groups in terms of probing depth preoperatively and postoperatively (P .05). Although there was a signicant difference between preoperative and 1 year postoperative measurements of attachment level in 3-cornered ap group (P .05), there was no signicant difference in the modied Szmyd ap group (P .05). There was also no signicant difference in mean clinical attachment level between modied Szmyd ap sites (0.56 1.15 mm) and 3-cornered ap sites (1.39 1.72 mm) at 1 year (P .05) (Table 5).

Table 3. POCKET DEPTHS ON THE DISTAL SURFACE OF THE SECOND MOLAR PREOPERATIVELY AND POSTOPERATIVELY

Flap Technique Technique II Technique I P value

Preoperative 2.78 0.65 2.89 0.58 .559


.05.

1 Week 4.61 2.30 6.22 2.44 .036*

2 Weeks 3.72 1.81 5.28 2.35 .018*

4 Weeks 3.22 1.52 4.44 1.95 .036*

1 Year 2.56 0.70 3.00 0.69 .075

*Signicant difference at P

Krtloglu et al. Modied Smyd Flap Versus 3-Cornered Flap. J Oral Maxillofac Surg 2007.

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Table 4. POCKET DEPTHS ON THE BUCCAL SURFACE OF THE SECOND MOLAR PREOPERATIVELY AND POSTOPERATIVELY

Flap Technique Technique II Technique I P value

Preoperative 1.33 0.49 1.56 0.70 .376


.05.

1 week 1.89 0.76 2.89 0.83 .001*

2 weeks 1.50 0.51 2.28 0.67 .001*

4 weeks 1.50 0.51 2.06 0.73 .019*

1 year 1.53 0.50 1.92 0.69 .077

*Signicant difference at P

Krtloglu et al. Modied Smyd Flap Versus 3-Cornered Flap. J Oral Maxillofac Surg 2007.

Discussion
The periodontal status of the adjacent mandibular second molars after the surgical removal of the impacted lower third molars has been investigated in several studies.8,12-15 The effects of ap design on the postoperative periodontal health status of second molars were investigated with different ap designs. Although some authors1,8 suggested that ap design inuenced primary wound healing, others3,4 suggested that ap design did not inuence periodontal health. Cunqueiro et al8 reported that the paramarginal ap has less buccal and distal probing depth of the second molar than the marginal ap at 5 and 10 days after surgery. However, there was no signicant difference between the 2 aps at 3 months. In the present study, ap design inuenced the probing depth of the distal and buccal surfaces of the second molar at 1 week, 2 weeks, and 4 weeks after surgery, but did not inuence it at 12 months. These differences between the 2 ap designs in the early stages could be related to the incision that left intact gingiva around the second molar and the sulcular incision that did not leave intact gingiva around the second molar. It is obvious that buccal probing sites were less affected in the early phases of healing with the modied Szmyd ap because no ap was reected on the buccal of second molars. After impacted third molar surgery, the remaining amount of periodontal ligament and gingival bers of the second molar is an important factor in periodontal healing.1,4,16 The differences in pocket depth at the distal and buccal

Table 5. CAL ON THE DISTAL SURFACE OF THE SECOND MOLAR PREOPERATIVELY AND POSTOPERATIVELY

Flap Technique Technique II Technique I P value

Preoperative

1 Year 0.56 1.15 1.39 1.72 .082

Abbreviation: CAL, clinical attachment loss. Krtloglu et al. Modied Smyd Flap Versus 3-Cornered Flap. J Oral Maxillofac Surg 2007.

surfaces at 1, 2, and 4 weeks were not attributable to a difference in plaque accumulation because of the similar plaque and gingival indices in both groups. Jakse et al1 reported that a ap design leaving gingiva intact on the distal and buccal aspect of the second molar, except at the distofacial edge, inuenced primary wound healing. Quee et al4 reported that ap design that left intact gingival collar on the distal aspect of the second molar did not prevent loss of attachment. In our study, the 3-cornered ap group had higher attachment loss than the modied Szmyd group, but there was no signicant difference between the 2 types of aps at 1 year postoperatively. In the study by Stephens et al,5 postoperative periodontal health status at 12 weeks was better than preoperative periodontal status. They found decreased mean probing depth around the second molars and no signicant difference between ap designs on postoperative periodontal health at 12 weeks. However, Rosa et al14 and Quee et al4 reported postoperative periodontal status at 6 months was worse than preoperative status. In our study, there was no signicant difference between preoperative and postoperative periodontal health status at 12 months for both techniques. Patient age might have an effect on second molar periodontal health after impacted third molar surgery.2,6,17 According to several authors, early removal of impacted lower third molars might have a benecial effect on the periodontal health of the adjacent second molar.6,7 Removal of the impacted lower third molar affected the periodontal healing of the second molar in the older age group ( 30 years old). However, even lower preoperative periodontal health did not affect the healing process in the younger age ( 20 years old).6 In the present study, the age range was 16 to 32 years (median, 20.8 years) and patients had no periodontal disease before surgery. The youth of the study population did not affect the comparison of the 2 types of aps. In addition, no signicant differences between preoperative and 1 year postoperative probing depth and attachment loss in both groups were attributable to younger individuals.

2210 In conclusion, careful surgical extraction with minimal trauma was important in the early phases of healing. The modied Szmyd ap, which left intact gingiva around the second molar, resulted in better primary periodontal healing than the 3-cornered ap after surgical removal of the fully impacted vertically and mesioangularly inclined third molar. Acknowledgment
The authors thank Gregory T. Sullivan of Ondokuz Mayis University in Samsun, Turkey for his proofreading.

MODIFIED SMYD FLAP VERSUS 3-CORNERED FLAP


7. Kugelberg CF, Ahlstrom U, Ericson S, et al: Periodontal healing after impacted lower third molar surgery. A retrospective study. Int J Oral Surg 14:29, 1985 8. Suarez-Cunqueiro MM, Gutwald R, Reichman J, et al: Marginal ap versus paramarginal ap in impacted third molar surgery: A prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 95:403, 2003 9. Krausz AA, Machtei EE, Peled M: Effects of lower third molar extraction on attachment level and alveolar bone height of the adjacent second molar. Int J Oral Maxillofac Surg 34:756, 2005 10. Silness J, Le H: Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 22:121, 1964 11. Le H, Silness J: Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 21:533, 1963 12. Richardson DT, Dodson TB: Risk of periodontal defects after third molar surgery: An exercise in evidence-based clinical decision-making. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100:133, 2005 13. Kan KW, Liu JKS, Lo ECM, et al: Residual periodontal defects distal to the mandibular second molar 6 36 months after impacted third molar extraction. A retrospective cross-sectional study of young adults. J Clin Periodontol 29:1004, 2002 14. Rosa AL, Carneiro MG, Lavrador MA, et al: Inuence of ap design on periodontal healing of second molars after extraction of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 93:404, 2002 15. Peng KY, Tseng YC, Shen EC, et al: Mandibular second molar periodontal status after third molar extraction. J Periodontol 72:1647, 2001 16. Karapataki S, Hugoson A, Kugelberg CF: Healing following GTR treatment of bone defects distal to mandibular 2nd molars after surgical removal of impacted 3rd molars. J Clin Periodontol 27:325, 2000 17. Yamaoka M, Tambo A, Furusawa K: Incidence of inammation in completely impacted lower third molars. Aust Dent J 42:153, 2000

References
1. Jakse N, Bankaoglu V, Wimmer G, et al: Primary wound healing after lower third molar surgery: Evaluation of 2 different ap designs. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 93:7, 2002 2. Ash MM, Costich ER, Hayward JR: A study of periodontal hazards of third molars. J Periodontol 33:209, 1962 3. Schoeld ID, Kogon SL, Donner A: Long-term comparison of two surgical ap designs for third molar surgery on the health of the periodontal tissue of the second molar tooth. J Can Dent Assoc 54:689, 1988 4. Quee TA, Gosselin D, Millar EP, et al: Surgical removal of the fully impacted mandibular third molar. The inuence of ap design and alveolar bone height on the periodontal status of the second molar. J Periodontol 56:625, 1985 5. Stephens RJ, App GR, Foreman DW: Periodontal evaluation of two mucoperiosteal aps used in removing impacted mandibular third molars. J Oral Maxillofac Surg 41:719, 1983 6. Kugelberg CF, Ahlstrom U, Ericson S, et al: Periodontal healing after impacted lower third molar surgery in adolescents and adults. A prospective study. Int J Oral Maxillofac Surg 20:18, 1991

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